MAUDE Adverse Event Report: DEXCOM INC. ANIMAS VIBE OYC

Device Problem Material Fragmentation (1261)

Patient Problem Foreign Body In Patient (2687)

Event Type  malfunction  

Manufacturer Narrative

The device has not been returned to animas. If the device is returned, an evaluation shall be completed and a supplemental report will be filed. No conclusions can be made at this time.

Event Description

On (b)(6) 2016, the reporter contacted animas alleging a cgm (dex 076) issue. It was alleged that the sensor wire broke off in the patient's abdomen. The patient was able to remove the segment of wire. There was no indication that the product caused or contributed to blood glucose excursion or infections. This complaint is being reported because the sensor broke off.

• Brand Name: ANIMAS VIBE
• Type of Device: OYC
• Manufacturer (Section D): DEXCOM INC.; 6340 sequence dr; san diego CA 92121 4356
• Manufacturer (Section G): DEXCOM INC.; 6340 sequence dr; san diego CA 92121 4356
• Manufacturer Contact: 6340 sequence dr; san diego, CA 92121-4356
• MDR Report Key: 6026854
• Report Number: 2531779-2016-28414
• Device Sequence Number: 1
• Product Code: MDS
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: P130007
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer
• Reporter Occupation: Patient
• Type of Report: Initial
• Report Date: 09/20/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/13/2016
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes

Device Operator

• Other Device ID Number: 1-MCBC-3760
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Event Location: No Information
• Date Manufacturer Received: 09/20/2016
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unkown
• Patient Age: 59 YR